MEDICARE: WELL CARE PHARMACY I, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy	PH03164	NV

General Provider Information

NPI Number	:	1184035487
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WELL CARE PHARMACY I, LLC

Provider Business Mailing Address
First Line	:	4101 WAGON TRAIL AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89118-4426
Country	:	US
Telephone Number	:	702-946-0353
Fax Number	:	702-946-0353

Provider Business Practice Location Address
First Line	:	5757 WAYNE NEWTON BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89111-8037
Country	:	US
Telephone Number	:	702-576-9545
Fax Number	:	702-946-0353

Authorized Official
Title or Position	:	PRESIDENT, CEO
Name	:	MARCELINO CASAL
Credential	:	RPH
Telephone Number	:	818-468-6355

Provider Enumeration Date	:	05/08/2014
Last Update Date	:	05/08/2014

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